Differences of the characteristics of uncontrolled versus controlled hypertensive patients, treated with at least three antihypertensive drugs: insights from the SNAPSHOT Europe study

Background Hypertension control remains challenging, particularly in patients treated with multiple antihypertensive classes. Identifying how uncontrolled patients differ from controlled patients, despite similar treatment intensity, may help improve management strategies. Purpose To compare clinical and treatment characteristics between uncontrolled and controlled hypertensive patients, treated with ≥3 antihypertensive drugs, in the SNAPSHOT Europe dataset. Methods SNAPSHOT is a cross-sectional epidemiological study of 9466 hypertensive patients from six European countries1. This subgroup analysis evaluates adults receiving ≥3 antihypertensive drugs from various classes (ACEi, ARB, CCB, diuretics, beta-blockers, central agents). Patients were categorized as uncontrolled or controlled, according to the 2018 ESC/ESH Guidelines. Group comparisons used X2, Wilcoxon or Z-tests with Holm-adjusted p-values (p adjusted →1.00, capped). Results 4830 patients were treated with ≥3 antihypertensive drugs, 3668 (75.9%) were uncontrolled whereas 1162 (24.1%) were controlled according to the guidelines. Almost all patients (90%) were at very high cardiovascular risk, according to SCORE2&OP. Uncontrolled patients were younger (median age [IQR] 68 [60-73] vs 71 [65-75] years), more frequently male (44.5% vs 38.1%), more often obese (46.9% vs 38.6%), and more often smokers (16.7% vs 11.4%), all p<0.05 (Table 1). After adjustment, none of the individual comorbidities differed significantly between the two groups. However, uncontrolled patients were less likely to present multiple comorbidities than controlled patients (28.7% with 3 or more comorbidities vs 34.8%, p=0.006). Hypertension duration was shorter in uncontrolled patients and their resting heart rate was higher (mean±SD, 74.9±11.1 vs 71.5±9.8 bpm, p<0.001). Treatment management of hypertension was similar between the two groups, including the use of single-pill combinations (SPC) (69.2% vs 67.3%), and the drug classes used, all p=1.0 (Table 2). Uncontrolled patients had shorter history of dyslipidaemia and received less often lipid-lowering therapy than controlled patients (89.5% vs 94.3%, p<0.001). The use of SPC was similar between groups (12.2% vs 12.4%, p=1.0). LDL-C levels were higher compared to controlled patients (mean±SD 119.3±45.9 vs 106.0±43.3 mg/dL, p<0.001). Conclusions Uncontrolled BP remains common in patients treated with ≥3 antihypertensive drugs. These patients were younger, more frequently male, obese, and smokers, with shorter duration of hypertension and dyslipidaemia, and with higher resting heart rate. Structured escalation, including heart rate–guided 4th-line therapy, are essential. These unmet needs support the potential role of upcoming quadruple SPC to achieve sustained BP control.